The dorsum and the hump

The hump is the commonest reason people ask for rhinoplasty and the step that decides most of what follows: take the roof off and the middle vault has to be rebuilt, keep the roof and it may push its way back up. The current literature is mostly about instruments and sequence: ultrasonic cutting in place of a chisel, reshaping the surface in place of resecting the structure, and the fixation that keeps a lowered dorsum down.

227papers on file 40this page is written from 10journals, 2011–2026 50open access, full text 175with a plain-language summary

Where these 227 papers were published

53Aesthetic Plastic SurgeryAesthetic Plast Surg
38Aesthetic Surgery JournalAesthet Surg J
37Plastic and Reconstructive SurgeryPlast Reconstr Surg
31Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
28Facial Plastic SurgeryFacial Plast Surg
18Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
12Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
6Archives of Facial Plastic SurgeryArch Facial Plast Surg
3JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
1Clinics in Plastic SurgeryClin Plast Surg

62011 82012 32013 52014 112015 72016 32017 82018 82019 132020 192021 182022 292023 192024 382025 322026

39 further papers on this topic came in through the history rather than the archive query: Skoog T 1966, Guyuron B 1998, Rohrich RJ 2004, Thornton MA 2006 and 35 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Ultrasonic cutting beats a chisel on everything except operating time

Nineteen randomised trials and 905 patients, GRADE-assessed: piezoelectric osteotomy produced less swelling on days 2 and 7, less bruising on days 1, 2 and 7, less pain on day 2, and no loss of mucosal integrity at all against a relative risk of 0.09 for the conventional groups. Operating time did not differ significantly and was heterogeneous. An earlier review of eight trials and 440 patients found the same direction, and a 113-patient comparison localised the benefit to the lower eyelid. This is the best-evidenced technical change in the whole rhinoplasty literature.

Rests on: Armanfar et al., 19 randomised trials · Kisel et al., eight trials · Vural and Koycu, eyelid comparison.

Removing the roof creates a problem that has to be closed in the same operation

Taking a hump down opens the roof of the middle vault, which leaves an open-roof deformity and, later, an inverted-V and a narrowed internal valve if nothing is done. The structural answer is a spreader graft or the upper lateral cartilage folded in as an autospreader. Prophylactic autospreader flaps in cosmetic primaries held nasal width at one year, a 1 mm increase that was not significant, while preserving breathing scores. In a randomised trial, hump resection with spreader flaps matched preservation on residual hump, width, projection, rotation, appearance and function.

Rests on: Jabbour et al., prophylactic autospreader flaps · Zarei et al., randomised against dorsal preservation.

Keeping the roof trades that problem for hump recurrence

Pooling 22 studies and 5,660 patients, dorsal preservation's own complication rates are low: hump recurrence 4.18%, revision 3.48%, postoperative deviation 1.13%, infection 1.89%. The technical literature since is almost entirely about pushing recurrence lower, fixation of the septum after a low strip, thermal rather than mechanical contouring of the upper lateral cartilage shoulders (recurrence 2.5% against 13.6%), and the seven anatomical blocking points that resist the dorsum coming down. The full comparison is on preservation rhinoplasty.

Rests on: Tham et al., meta-analysis of 5,660 patients · Çelik and Tuluy, fixation modification · Şibar et al., electrocautery against scalpel · Cason et al., five tenets.

The two approaches produce dorsums nobody can tell apart

Both widen the dorsal aesthetic lines by the same measured amount on AI analysis of matched cohorts. Raters (the public, plastic surgeons and rhinoplasty surgeons) identified which approach had been used 52.9% of the time, which is chance. Crowdworkers could tell that a structural patient had had surgery and could not tell for a preservation patient, with equal aesthetic improvement in both. Whatever separates these operations, it is not visible in the result to anyone but the surgeon who did it.

Rests on: Xu et al., dorsal aesthetic lines measured · McCleary et al., can raters tell · Alford et al., crowdsourced.

Bone is not the same thickness on both sides, and the asymmetric side is the thick one

Three-dimensional CT of 250 primary rhinoplasty patients: 35.2% had asymmetric bony vaults, the bone was thickest at the middle of the lateral osteotomy path, thicker in men at every point, and in an asymmetric vault the deviated side was thicker and the other side thinner than in a symmetric vault. That is a direct argument for planning the two sides differently, which is what the published osteotomy algorithm does, using septal position, alar length, pyramidal length and the side the deviation starts on to choose the level and number of cuts across 521 patients.

Rests on: Kim et al., bony vault on CT · Cabbarzade, the SELF algorithm in 521 patients.

Above the hump and below it, the soft tissue decides the profile

Lowering a high radix creates dead space that fills with fibrosis and puts the radix height back up; a transosseous fixation suture in 30 patients halved the change in nasofrontal angle at twelve months (4.0° against 6.2°) with higher satisfaction. Below the hump, transecting Pitanguy's midline ligament in closed low-strip preservation prevented supratip depression entirely (0 of 20 against 4 of 16). And in noses where the dimensions do not need changing, superficial dorsal modification alone (no resection, no reconstruction) produced no revisions across 147 patients at a mean 27 months.

Rests on: Akiner et al., the radix suture · Erdal and Genç, ligament transection · Zholtikov et al., dorsal modification in 147 patients.

By step

The hump operation, in the order it is done, and what the papers say about each step.

Reading the dorsum before touching it

Bony vault symmetry, bone thickness along each osteotomy path, nasal bone length, the radix-to-tip distance and the kyphion angle all predict how the operation will go, shorter nasal bones and lower kyphion angles correlating with better dorsal preservation outcomes on CT-based scoring of 43 patients. Asymmetry is the rule rather than the exception: a third of primary patients.

Key papers: Kim et al. · Kemal et al., radiological predictors.

Lowering the hump: resect, rasp, or reshape the surface

Three families. Resection takes the osseocartilaginous hump off and the midvault is rebuilt. Rasping and superficial modification change the surface without touching the structures that hold the dorsum up, which in the right nose is enough on its own. Surface preservation techniques (the spare roof family, subdorsal strips, the Z-flap) reshape the roof and remove cartilage from beneath the dorsum instead.

Key papers: Zholtikov et al. · Barrera, subdorsal strip methods · Nakamura et al., spare roof technique B · Ferreira et al., NOVA spare roof and the sail manoeuvre.

Moving the pyramid: push-down and let-down

The foundation techniques drop the whole bony pyramid, with or without removing a wedge of bone at its base. Outcomes and their argument are on preservation rhinoplasty; the single largest series is 1,191 consecutive primaries with revision rates of 3.4%, 9.9% and 3.3% across three eras of indication-setting.

Key paper: Saban and Sachanandani, 1,191 cases.

Osteotomies

Lateral, medial, transverse. The level and number are chosen from the anatomy: the published algorithm reads septal position at the floor, external alar length, lateral pyramidal length and the side the deviation starts on, and performed 401 double-lateral and 85 high-lateral osteotomies accordingly in 521 patients with no serious complications. In a revision where the lines already exist, digital pressure can recreate them without an osteotome and without opening dead space. Where an osteotome is used, ultrasonic instruments cut bone without cutting mucosa.

Key papers: Cabbarzade · Lisiecki et al., digital osteotomies · Armanfar et al..

Rebuilding or supporting the middle vault

Spreader grafts, spreader flaps and autospreaders after resection; internal spreader and external strip grafts under a preserved dorsum for a concave upper lateral cartilage or a collapsing W-ASA segment. In 152 preservation patients, 52 needed that support and satisfaction scores rose from 56.5 to 92.5.

Key papers: Jabbour et al. · Öztürk, external strip and internal spreader.

The dorsum that has to be rebuilt from nothing

In revision, where the dorsum has been over-resected or a graft has warped, layered constructions (perichondrium, a rib lamina and fascia in one sandwich) are reported in more than 300 cases, and the rest of that literature is on revision rhinoplasty.

Key paper: Robotti et al., the SPLF graft.

Finishing: the radix, the width and the soft tissue

A radix that is lowered without fixation comes back up; a middle third narrowed under a preserved dorsum may need a suture; and swelling above the tip is a soft-tissue problem managed by ligament handling and drainage rather than by cartilage.

Key papers: Akiner et al. · Erdal and Genç · Uzunoğlu et al., drains after piezo osteotomy.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Dorsal hump: the convexity on the profile, made of bone above and cartilage below, meeting at the rhinion. Reducing it means dealing with both materials and with the join. [36594157]
Keystone area: where the nasal bones, upper lateral cartilages and septum all meet. Preservation techniques are defined by leaving it articulated. [40277124, 36988641]
Open-roof deformity: the flat-topped gap left when a hump is resected and the middle vault is not closed. [42415377]
Inverted-V deformity: the visible shadow where the nasal bones end and unsupported upper lateral cartilages have collapsed inward, months after a resection. [42415377]
Spreader graft, spreader flap, autospreader: a strip of cartilage placed between septum and upper lateral cartilage (graft), or the cartilage itself folded inward and fixed (flap/autospreader), to hold the midvault open. [42415377, 38366551]
Dorsal aesthetic lines (DALs): the paired highlights running from brow to tip. Both hump techniques widen them by about the same measured amount. [41369038]
Radix and nasofrontal angle: the root of the nose between the eyes, and the angle it makes with the forehead. Lowering the radix without fixation lets it re-fill. [41834234]
Kyphion angle: a radiological measure of where and how sharply the bony hump peaks; larger angles predicted worse dorsal preservation outcomes. [40179243]
Rasping and superficial dorsal modification: filing or otherwise reshaping the surface of the dorsum without resecting or reconstructing what holds it up. [38992914]
Push-down and let-down: lowering the mobilised bony pyramid, with or without removing a wedge of bone at its base. [42467617]
Spare roof technique: a surface preservation technique that reshapes the roof rather than removing it; variants avoid disarticulating the lateral keystone area. [39087910, 40277124]
Subdorsal strip (high strip and low strip): removing a strip of septal cartilage under the dorsum, high or low, to let the dorsum settle. Where fixation matters most. [38648529, 39023572]
Lateral, medial and transverse osteotomy: the controlled bone cuts that narrow or straighten the pyramid. Level and side are chosen from measured anatomy, not by default. [35112156]
Webster's triangle: the area at the base of the lateral osteotomy left uncut to avoid obstructing the airway; also one of the blocking points that resists dorsal lowering. [38722588]
Piezoelectric (ultrasonic) osteotomy: cutting bone with an ultrasonic tip that does not cut mucosa or soft tissue. Less swelling, bruising and pain in pooled trials. [42013314]
Digital osteotomy: recreating a previous osteotomy line with finger pressure, avoiding new dead space in revision. [36877619]
W-ASA segment: the area between the W-point and the anterior septal angle, which can collapse under a preserved dorsum and needs support. [40327831]
Pitanguy's midline ligament: the band running from the dorsum down to the tip; transecting it prevented supratip depression in closed low-strip preservation. [35908175]
Minimal clinically important difference (MCID): the smallest change in a score a patient would notice. Both hump techniques exceeded it for appearance. [41369038]

The papers this rests on

The 40 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

ASJ
Piezoelectric Versus Conventional Rhinoplasty: A GRADE-Assessed Systematic Review and Meta-analysis of Randomized Controlled Trials
Armanfar S, Ardakani MR, Vahidiataabadi M

2026PMID 42013314Summary
APS
Comparison of Dorsal Preservation Rhinoplasty and Dorsal Hump Reduction Rhinoplasty: A Systematic Review and Meta-Analysis of Postoperative Outcomes
Khatib M, Skorochod R, Wolf Y

2026PMID 42418006Summary
APS
The Evolution of the SPF-SPLF Graft in Rebuilding the Dorsum in Revision Rhinoplasty-an Update in an Over 300 Case Series
Robotti E, Clauss A, De Bernardis R et al.

2026PMID 40826294Summary
FPS
Functional Outcomes of Dorsal Preservation Rhinoplasty: A Systematic Review and Meta-analysis
Chan C, North AS, Khademi Mansour HR et al.

2026PMID 42532128Summary
FPSAM
Invited Commentary: "Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods" by Barrera
Saman M, Saban Y

2026PMID 38648531
PRS
Clarification and Classification of Dorsal Preservation Rhinoplasty: Lessons from a Continuous 1,191-Case Experience
Saban Y, Sachanandani NS

2026PMID 42467617Summary
PRS
Dorsal Preservation versus Conventional Hump Reduction Rhinoplasty: A Seven-Year Review of Patient Reported Outcomes and Concurrent Operative Techniques
Wei EX, Fu B, Huang H et al.

2026PMID 42053436Summary
APS
Comparison of Patient-Reported Outcomes Between Dorsal Preservation and Conventional Dorsal Hump Reduction Rhinoplasty: A Systematic Review and Meta-Analysis
Kim DH, Jang DW, Hwang SH

2025PMID 40195129Summary
FPSAM
Preservation Rhinoplasty Versus Structural Rhinoplasty in Dorsal Hump Reduction: A Systematic Review and Meta-Analysis of Randomized Controlled Studies
Shim SR, Kim JY, Lee SM et al.

2025PMID 40227917Summary
PRS
Refining Patient Selection in Hybrid Dorsal Preservation Rhinoplasty: A Review of 50 Patients
Ganesh Kumar N, Sherif R, Rohrich RJ

2025PMID 40327836Summary
FPSAM
Comparison of Dorsal Preservation Rhinoplasty Techniques: Functional and Aesthetic Review of Subdorsal Septal Strip Methods
Barrera JE

2024PMID 38648529Summary
APS
A Comparison Between Piezosurgery and Conventional Osteotomies in Rhinoplasty on Post-Operative Oedema and Ecchymosis: A Systematic Review
Kisel J, Khatib M, Cavale N

2023PMID 36163553Summary
FPS
Modified Dorsal Split Preservation Hybrid Rhinoplasty for Cartilaginous Pushdown and Full Letdown Applications: A PROM-Based Review of 100 Consecutive Cases
Robotti E, Cottone G, Leone F

2023PMID 36787789Summary
APS
Invited Discussion on: SELF-A Novel Algorithm for Deciding the Position of Lateral Osteotomies in Rhinoplasty Patients with Minimal External Deviation
Zholtikov V

2022PMID 35299264
APS
SELF: A Novel Algorithm for Deciding the Position of Lateral Osteotomies in Rhinoplasty Patients with Minimal External Deviation
Cabbarzade C

2022PMID 35112156Summary
FPSAM
Clinical Outcomes in Dorsal Preservation Rhinoplasty: A Meta-Analysis
Tham T, Bhuiya S, Wong A et al.

2022PMID 35172105Summary
ASJ
Comparison of Functional and Cosmetic Outcomes Between Dorsal Preservation and Spreader Flap Rhinoplasty: A Randomized Trial
Zarei R, Most SP, Amali A et al.

2024PMID 38366551Summary
PRS
Dorsal Preservation versus Open Structural Rhinoplasty: Can We Tell the Difference between Aesthetic and Functional Outcomes?
McCleary S, Khan A, Khetpal S et al.

2025PMID 40331571Summary
ASJ
Crowdsourced Assessment of Aesthetic Outcomes of Dorsal Preservation Rhinoplasty
Alford JA, McCleary S, Roostaeian J

2025PMID 39498873Summary
ASJ
Postoperative Differences in Dorsal Aesthetic Lines in Patients Undergoing Dorsal Preservation Rhinoplasty and Conventional Hump Resection
Xu L, Huang H, Kandathil CK et al.

2026PMID 41369038Summary
ASJ
Scalpel vs Electrocautery for Upper Lateral Cartilage Contouring in Dorsal Preservation Rhinoplasty: A Retrospective Comparative Study
Şibar S, Erdal AI, Okutan MT

2025PMID 40972537Summary
PRS
Modification of Low-Septal-Strip Septoplasty to Reduce Hump Recurrence in Dorsal Preservation Rhinoplasty
Çelik V, Tuluy Y

2025PMID 39023572Summary
PRS
Preventing Hump Recurrence in Dorsal Preservation Rhinoplasty: The 5 Key Tenets
Cason RW, Goksel A, Sergesketter AR et al.

2025PMID 38722588Summary
ASJ
Radiological and Anatomical Parameters as Determinants of Success in Dorsal Preservation Rhinoplasty
Kemal Ö, Tahir E, Çolak O et al.

2025PMID 40179243Summary
ASJ
Dorsal Modification: Practical Applications in Rhinoplasty
Zholtikov V, Ouerghi R, Kosins A

2024PMID 38992914Summary
ASJ
Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty
Erdal AI, Genç İG

2023PMID 35908175Summary
FPSAM
Functional and Aesthetic Outcomes of Let Down Dorsal Preservation Rhinoplasty
Sozansky Lujan J, Goldfarb JM, Barrera JE

2023PMID 36282789Summary
ASJ
Optimizing Closed-Approach Preservation Rhinoplasty by Ultrasonic Piezo-assisted Techniques for Enhanced Precision
Guilarte R, Malzone G

2025PMID 39812015Summary
FPSAM
Comparison of Upper and Lower Eyelid Edema and Ecchymosis Following Rhinoplasty: A Study of Osteotome Versus Piezoelectric Techniques
Vural O, Koycu A

2026PMID 40566666Summary
FPSAM
The Effect of Subperiosteal Drain Placement on Periorbital Edema and Ecchymosis Following Ultrasonic Piezoelectric-Assisted Rhinoplasty: A Prospective Comparative Study
Uzunoğlu E, Hazır B, Ateş MS et al.

2026PMID 41452163Summary
ASJ
An Anatomic Analysis of the Bony Vault: From the Perspective of Osteotomy in Rhinoplasty
Kim SJ, Kim TH, Lee KH

2023PMID 36594157Summary
FPSAM
The Radix Suture: A Strategy for Prevention of Soft Tissue Fullness After Radix Reduction in Rhinoplasty
Akiner U, Krasteva-Christ G, Haddad S

2026PMID 41834234Summary
ASJ
Dorsal Width and Functional Outcomes with use of Autospreader Flaps in Cosmetic Rhinoplasty
Jabbour N, Pelligrini W, Shehan J et al.

2026PMID 42415377Summary
PRS
The External Strip and Internal Spreader Graft Combined with Dorsal Preservation Rhinoplasty
Öztürk G

2025PMID 40327831Summary
FPSAM
Feasibility of Dorsal Preservation Rhinoplasty for Hump Nose Reduction in Asian Population
Jin HR, Jeon YJ

2024PMID 39056121Summary
PRS
Dorsal Preservation Rhinoplasty in Asian Hump Noses
Jin HR, Kim Y, Jeon YJ

2024PMID 36988641Summary
FPSAM
Dorsal Preservation Rhinoplasty Using a Ferreira-Nakamura Spare Roof Technique B Highlighting the Low Septal Cartilage Strip
Nakamura F, Ferreira MG, Rodrigues de Oliveira GS et al.

2024PMID 39087910Summary
FPSAM
NOVA Spare Roof Technique and the Sail Maneuver-Vectorial Rhinoplasty Without Lateral Keystone Area Disarticulation
Ferreira MG, Lyrio TM, Tamanqueira P et al.

2025PMID 40277124Summary
PRS
Revision Rhinoplasty Finesse with Digital Osteotomies
Lisiecki JL, Chiodo MV, Rohrich RJ

2024PMID 36877619Summary
FPSAM
Dorsal Preservation Rhinoplasty: The Perspective of "Preservers" vs. "Structured" Surgeons
Santos M, Most SP, Wayne I et al.

2025PMID 39505713Summary

What is still contested

Whether preservation or resection is better for the hump is not settled: four randomised trials favour preservation, the largest functional meta-analysis finds no difference, and cohort data show an advantage at six months that is gone at twelve. [40227917, 42532128, 42053436]
Piezoelectric osteotomy's effect on operating time is genuinely unknown, the pooled estimate is heterogeneous and non-significant, and cost is rarely reported. [42013314, 36163553]
Prophylactic autospreader flaps preserved width and function in one cohort; no trial tests whether they prevent the inverted-V they are placed to prevent. [42415377]
The radix suture, superficial dorsal modification and the ligament manoeuvres are each a single surgeon's series against a historical or internal control. [41834234, 38992914, 35908175]
Follow-up rarely passes two years, in an operation whose commonest late failures (recurrence, irregularity, inverted-V) appear late. [35172105, 42418006]
Bony vault asymmetry is documented in a third of patients but no outcome study on file tests whether side-specific osteotomy planning changes the result. [36594157, 35112156]